In 2025, revenue code 0421 remains the standard UB-04 code for “Physical Therapy – Visit Charge,” crucial for home health and outpatient billing accuracy. This guide covers its definition, CMS updates, payer rules, documentation tips, and common errors—so you avoid denials and get paid timely.
What Is Revenue Code 0421?
Revenue code 0421 denotes the “physical therapy visit charge” on the CMS-1450 claim form (UB-04).[1] It applies each time a therapist provides a skilled, direct visit—distinct from hourly or evaluation codes.[2]
2025 CMS & NUBC Updates
NUBC Confirmation
In CY 2025, the National Uniform Billing Committee (NUBC) has not altered the 042X series. Code 0421 remains “visit charge” under Physical Therapy.[1]
Annual Therapy Update
CMS’s “Annual Therapy Update” confirms that therapy revenue codes remain valid for 2025 facility billing.[9] No new therapy revenue codes were added or retired.
Billing & Claim-Form Guidelines
CPT/HCPCS Linkage
Every line billed with 0421 must include a matching CPT code—commonly 97110 (therapeutic exercise) or 97112 (neuromuscular re-education). Missing CPT linkage triggers denials under UHC policy.[3]
UB-04 Field Placement
On UB-04, enter 0421 in Form Locator (FL) 42 (Revenue Code), the CPT/HCPCS code in FL 44, and related charges in FL 46. Bill Types 011x/012x cover inpatient/outpatient; 032x/034x apply for home health under or outside of plan.[1]
Telehealth Visits
Through March 31, 2025, PT telehealth visits may be billed with 0421 if the originating site qualifies. Use Place of Service 02 and document real-time interaction per CMS telehealth guidance.[4]
Payer-Specific Policies
Medicare FFS
Medicare Fee-for-Service covers 0421 visits when medically necessary and skilled. No local coverage restrictions exist, though your A/B MAC may issue transmittals on required modifiers.[1]
UnitedHealthcare
UnitedHealthcare’s facility policy mandates CPT linkage for 0421 claims. Absence of a valid CPT/HCPCS code may result in denial or adjustment.[3]
Horizon Blue Cross Blue Shield
Horizon BCBS requires CPT or HCPCS codes for 0421 claims. Claims without approved procedure codes will pend or deny per their hospital outpatient policy.[5]
Anthem Blue Cross
Anthem’s facility revenue code policy specifies that 0421 must be supported by medical records. Non-compliant submissions risk denial under C-18003.[6]
Excellus BCBS
Excellus BCBS lists 0421 in its “Revenue Codes Requiring CPT” bulletin. Ensure you attach the correct CPT code to avoid payment disruption.[7]
Documentation Best Practices
Document each PT visit with objective findings, interventions performed, and patient response. Use standardized measures (e.g., Tinetti, Berg Balance). Clear notes prevent denials for “insufficient documentation.”[8]
Common Billing Errors & Solutions
- Missing Procedure Code: Always link CPT 97110/97112 to 0421 lines.
- Wrong Bill Type: Use correct UB-04 Bill Type. Home health requires 032x/034x.
- Exceeding Visit Limits: Verify payer frequency limits to avoid overbilling.
- Telehealth Missteps: Confirm POS 02 and document interactive telehealth details.
Frequently Asked Questions
Can I bill 0421 for a group PT session?
No—group sessions use 0423 (“Group Rate”). Code 0421 applies only to individual visit charges.[2]
Is a modifier needed with 0421?
Generally no. Use KX only when exceeding PDGM visit thresholds or payer-specific criteria.[10]
How often can I bill 0421?
Frequency depends on payer policy. Medicare has no limit; private plans may restrict to daily or per-episode caps.[9]